To save time, a sample model program is provided as a reference when developing or improving your IIPP. The numbers in the sample model program correspond to the IIPP questions listed below. Before you start, review the sample model program and IIPP questions.

Step 3 - Answer the IIPP Questions

To develop your own written IIPP customized to your workplace, answer the IIPP questions below. Each question you answer will automatically appear underlined in your written Injury and Illness Prevention Program. To produce a complete written IIPP which is specific to your workplace you must fully answer all the IIPP questions. Your answers must be specific to your work place policies and procedures and the work activities your employees actually perform. In addition to your answers to these questions, all of the other IIPP requirements will also automatically be included in your written IIPP when it is printed.

For some of the IIPP question below, (examples) of answers are included. These examples are intended to help by giving you an idea of what other employers have in their written IIPP programs. Depending on your workplace policies and procedures and the work activities your employees actually perform, these examples may or may not be appropriate for you to use when answering the IIPP questions.

Remember that an effective IIPP is not just a paper program. For your IIPP to be effective you must fully put it into practice in your workplace.

IIPP Questions

Please read before you begin: When navigating away from this page after you have started to fill out the questionnaire below, click the browser back button to get back to the form so your answers will NOT be cleared.

1. Responsibility

1.) The name, title and contact information for the person(s) that has overall responsibility for ensuring that our company has an effective IIPP is:

2.) The name of our company is:

3.) Copies of our IIPP are available at the following locations:

2. Compliance

4.) We recognize our employees that consistently perform safe and healthful work practices by - Examples:

6.) Other means (e.g., peer mentoring) in addition to those listed in the Compliance section of our written IIPP that we use to ensure employee compliance with safe and healthful work practices include - Examples:

8.) We arrange for our employees to anonymously notify management of safety and health concerns without fear of reprisal by - Examples:

9.) Other means (in addition to those listed in the Communication section of our written IIPP) we use to ensure communication with employees include - Examples:

10.) Our organization elects to use a labor/management safety and health committee meeting all the requirements of T8CCR 3203 (7)(c)(1) - (7) to comply with the communication requirements of subsection (a)(3) of T8CCR 3203 [enter yes or no].

11.)Our organization has less than ten employees and complies with the requirements of subsection (a)(3) of T8CCR 3203 by communicating and instructing employees orally [enter yes or no].

4. Hazard Assessment

12.) The name of the person(s) conducting periodic inspections to identify and evaluate workplace hazards is(are):

14.) The name of the person(s) conducting investigations of our workplace injuries, illnesses and accidents, hazardous substance exposures and near-misses is (are):

To help you conduct investigations and take corrective actions for accidents, hazardous substance exposures and near-misses in your workplace use the Investigation/Corrective Action Report under "Tools" of this eTool.